The Economic and Social Review, Vol. 49, No. 2, Summer 2018, pp.201-215
Paul Gorecki
The Digest Series presents summaries of papers that make contributions to policy debates that have already been published by the identified authors in cited outlets.
Introduction
Public policy in Ireland has committed to extending free GP care to all, on a phased basis. In 2015, under 6s and over 70s became eligible for free GP care. It has recently been announced that free GP care for the under 12s is to be rolled out in 2020. Free GP care was previously restricted to those qualifying for a means tested Medical Card or GP Visit Card. In May 2015, 41.0% of the population was in receipt of free means tested GP care. Private patients were charged an estimated €50 per GP visit. The principal concern here is how the abolition of this fee will affect the utilisation of GP services.
This digest highlights the implications for the accurate estimation of the impact of free GP care on the cost of state payment fees to GPs; the appropriate planning of the medical workforce; the potential costs of universal health insurance; and the quality of GP care. An increase in demand for GP services with the provision of free GP care may mean that the same level of care will not be delivered.
Background
Work by a group of Dublin GPs, Behan et al. (2013; 2014) suggested that extending free GP care to all will result in an extra 4.4 million GP visits annually. Although these estimates received widespread attention (e.g. IMO, 2014; Williams, 2015) questions have been asked about their veracity.
Data and Issues
Behan et al. (2013; 2014) estimated the impact of free GP care based on the administrative data from six GP practices. Scientifically there were problems with this data. These GP practices were non-randomly selected. Their methodology was not validated or independently reviewed. They represented a small proportion of all GP practices – six out of 2,093 or less than 0.5%. However, Behan et al. (2013) argue that their sample is comparable to the national population in terms of age and Medical Card status.
Addressing the problem
Across the six GP practices used by Behan et al. (2013), the average number of GP consultations for private patients over 18 was 4.8 in 2012- 2013. The corrected rate, allowing for the fact that some private patients did not visit the GP practice in the year in question, was 3.35. Gorecki (2018), , Wren et al (2015) and McGovern (2015) suggest that Behan et al.’s estimates of the increase in the number of GP visits due to free GP care are overestimated.
Behan et al. assume that public (i.e. those patients with a GP Visit Card) and private (i.e. those patients without a GP Visit Card or a Medical Card) patients would visit the GP with the same frequency but for the fact that private patients do not have access to free GP care. Inherent in this approach is the view that public and private patients share the same characteristics that determine the demand for GP services in terms of patient ‘need,’ socio-economic factors and financial incentives, except for the fact that one group must pay for GP services. Accordingly, once private patients are in receipt of a free GP Visit Card, they will visit GPs with the same frequency as those currently in receipt of such a card.
Behan et al. data do not allow for an examination of patient characteristics by the status of their GP cover. However supplementary analysis using Growing Up in Ireland (GUI), the Irish Longitudinal Study on Aging (TILDA) and special modules of the Quarterly National Household Survey (QNHS) do permit such an exploration. These surveys are based on patient self-reporting (or recall) over a year. Public patients are broken down into those with private health insurance (PHI) and those with no cover (No Cover). Furthermore, patients holding a Medical Card or GP Visit Card are usually combined into one category.
Analysis of these surveys show that people on a Medical/GP Visit Card have a lower health status, lower levels of education and lower levels of income. They have a higher demand for GP services than those with PHI or No Cover. Factors such as health status explain a considerable proportion of the variance in GP visiting rates. Determinants of GP visits (i.e. patient ‘need,’ socio- economic characteristics and financial incentives) results in a reduction in the difference between the GP visit rates of public and private patients. For example, for the over 50s, the difference in annual GP visits for a private patient with no private health insurance as compared to a public patient (Medical/GP Visit Card) falls from 4.1 to 1.5. Hence it is inappropriate to argue that if all those on No Cover or PHI (i.e. private patients) were to receive a Medical/GP Visit Card that they would replicate the same GP visiting rates as those with a Medical/GP Visit Card.
Free GP Care to All
The impact of free GP care in Ireland on the utilisation of GP services has been estimated in order to help with future medical manpower planning and in quantifying the potential costs of universal healthcare. These estimates are again based on retrospective patient self-reporting surveys and relies on the “best available data”- GUI, TILDA, QNHS and Survey of Income and Living Conditions (SILC) or Living in Ireland Surveys (LIS), a forerunner of SILC (18-49 years).
McGovern (2015) estimates that extending free GP care to all in 2015 would have resulted in an increase in the number of GP visits by 3.4 million or 23%. Inestimating the change in consultation rates should free GP care be introduced, adjustments were made to account for the association between deprivation and poor health outcomes, among other factors. Wren et al. (2015, pp. 32-3), as part of a larger study into the impact of universal health insurance in Ireland, estimate that extending free GP care to all in 2013 would have resulted in an increase in the annual number of GP visits by 2.5 million or 18.2%. They took into account “age, gender, socio-economic factors, rurality and health status” in their analysis.
Table 1: Estimates of GP Visits Rates, Public & Private Cover, Impact of Free GP Care, by Age Group, Ireland, 2009-2013.a
a. Columns 1 and 3 are drawn from McGovern (2015, Table 6, pp. 21-23); column 4 from Nolan & Layte (2017, p. 67), Nolan, Ma & Moore (2016, Table 4, p. 12) & Ma & Nolan (2017, p. 1422); and, column 2 from Supplementary Tables A.1 to A.4, Williams et al (2009, Figure 5.2, p.67), HSE (2008), CSO (2011a, 2012). Supplementary Table A.10 provides much greater detail on the derivation of columns 2 and 4, including the time period to which the estimates refer, generally 2009-2013.
Private Patients
McGovern (2015) predicts, for private patients, an increase of 3.4 million GP visits (or 55%) due to the extension of free GP care for all. In contrast, Wren et al. (2015) predict an increase of 2.5 million (or 48%) extra GP visits.
Using supplementary data Gorecki (2018) presents alternative estimates. He uses additional published sources such as Williams et al. (2009) and CSO (2011a), but also on tabulations prepared by GUI and TILDA (Supplementary Tables) see Table 1. Although the Wren et al’s. (2015) estimates on the impact of free GP care are to be preferred to those of McGovern (2015) this conclusion is tentative in view of the absence of estimates for those aged six to 44 in Column 4 of Table 1.
There is, however, one caveat that suggests that these estimates are upper bounds. This reflects the fact that what is typically being quantified in Table 3 and by Wren et al. (2015) is the effect of receiving a Medical Card or a GP Visit Card, rather than just a GP Visit Card. As Ma and Nolan (2017) note gaining a Medical Card entitles the holder to prescription medicine coverage which is not included when a private patient is granted a free GP Visit Card. Ma and Nolan (ibid, p. 1425) cite evidence which finds that “prescription drug coverage affects GP visiting rates.”
Conclusion
Due to the lack of national registration and associated administrative data, other data sources are used for assessing the impact of the extension of free GP care to all private patients. Available estimates of the impact of free GP care vary from an additional 2.5-4.4 million GP visits. While the latter estimate is biased upwards, it nevertheless has gained wide currency.
These estimates are likely to result in different implications for the delivery of GP services. The lower the likely increase in GP visits the more likely it is that the increased demand could be accommodated within existing capacity and structures. With an increase in demand, the more likely it will be that in order to meet the extra demand, the supply of GPs would need to be increased and/or the current structures for delivering GP services could be reformed.
References
Behan, W., D. Molony, C. Beame and W. Cullen (2013). “Are Irish Adult General Practice Consultation Rates as Low as Official Records Suggest? A Cross Sectional Study of Six General Practices”, Irish Medical Journal, Vol. 106, No. 10, Nov/Dec, pp. 297-299.
Behan, W., D. Molony, C. Beame and W. Cullen (2014). “Does Eliminating Fees at Point of Access Affect Irish General Practice Attendance Rates in the Under 6 Years Old Population? A Cross Sectional A Study of Six General Practices”, Irish Medical Journal, Vol. 107, No. 4, April, pp. 121-122.
Central Statistical Office (CSO) (2011a). Health Status and Health Service Utilisation. Quarter 3 2010, Cork: CSO. http://www.cso.ie/en/media/csoie/releasespublications/documents/labourmarket/2010/healthstatusq32010.pdf.
Gorecki, P. (2018). The Impact of Free GP Care on the Utilisation of GP Services in Ireland: An Evaluation of Different Approaches, The Economic and Social Review, Vol. 49, No. 2, Summer 2018, pp.201-215.
Irish Medical Organisation (IMO) (2014). “Research Suggests Extending Free GP Visit Cards to Children Could Lead to 750,000 Extra GP Visits a Year”, Press Release. 14 April 2014. Dublin: IMO.
Ma, Y. and A. Nolan (2017). “Public Healthcare Entitlements and Healthcare Utilisation Among the Older Population in Ireland”, Health Economics, Vol. 25, Issue 11, November, pp. 1412-1428.
McGovern, E. (2015). Future Demand for General Practitioners 2015-2025, Medical Workforce Planning. National Training and Planning, HR Directorate. Dublin: HSE.
Williams, J., S. Greene, E. Doyle, E. Harris, R. Layte, S. McCoy, C. McCrory, A. Murray, E. Nixon, T. O’Dowd, M. O’Moore, A. Quail, E. Smyth, L. Swords and M. Thornton (2009). The Lives of 9-Year-Olds, Dublin: Stationery Office.
Wren, M-A., S. Connolly, N. Cunningham (2015). An Examination of the Potential Costs of Universal Health Insurance in Ireland, Research Series No 45, Dublin: The Economic and Social Research Institute.